Disclaimer: I certify that I am authorized by my company to request and receive information from ShelterPoint Life regarding Third Party Sick Payments to employees of my company. I understand and agree that ShelterPoint Life is providing this preliminary third party sick payment report ("Report") for informational purposes only and this Report is NOT intended to be filed with any government authority or used as the basis for end-of-year payroll filings. I acknowledge that this Report may not reflect the total payments to be made for the applicable tax year, and that any fees and penalties incurred as a result of the use of this Report will be the sole responsibility of my company, and ShelterPoint Life shall have no liability to my company of any kind whatsoever.

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